The Promotion of perinatal mental health by nurses in non-maternity settings

By Dr Catriona Jones. RM, PGCE, FHEA @CatrionaJones6 @EBNursingBMJ

It is maternal mental health awareness week, a week dedicated to talking about mental illness during pregnancy and after childbirth. Any health care practitioner (HCP) can meet a woman in need of support and treatment for perinatal mental illness (PMI). It is important to take this opportunity to raise awareness of perinatal mental health and illness to health care practitioners (HCPs) working in non-maternity settings, in order to promote perinatal wellbeing and to improve women’s access to appropriate support and treatment.

Perinatal mental illness (PMI) refers to mental health and psychiatric disorders prevalent during pregnancy and up to 1 year after childbirth (O’Hara & McCabe, 2013). It is important that women who are at risk of, or experiencing PMI are identified and provided with appropriate support and treatment. Perinatal mental health (PMH) services currently accept referrals for women who have given birth within the last year. Research supports the idea that there may be some benefit in extending this period to 2 years, however, further evidence is needed on whether extension to the second year is effective and cost-effective (Howard and Kalifeh, 2020). HCPs should recognise that research suggests women with children up to the age of 2 can benefit from PMH support and treatment.

Impaired wellbeing in the perinatal period can have serious and long lasting implications for the women, their babies, as well as her baby, partner and family (Glover et al 2010; O’Donnell et al 2013). During pregnancy or within the first year of childbirth, 10 – 20% of women develop a mental health problem (Bauer, et al., 2014). The majority of women who need support and treatment will be identified by midwives, health visitors and general practitioners. In these cases, a referral will be made into primary mental health or specialised PMH services, depending on the estimated severity of the condition. It is important to remember that a number of women in need of PMH support and treatment may present to general healthcare/hospital settings. Many women no longer have regular contact with a midwife or health visitor beyond 6 months post-partum, it is fair to say that nurses in non-maternity settings have an important contribution to make in terms of reducing suffering and positively impacting on families.

Traditionally, the focus of mental health across the continuum of pregnancy and childbirth has been on postnatal or perinatal depression, however over the last 10 years there has been a recognition of a number of psychiatric/psychological disorders, constituting a spectrum of PMI including generalised anxiety disorder, panic disorder, post-traumatic stress disorder, tokophobia, obsessive compulsive disorder, as well as more severe conditions such as bipolar affective disorder, schizophrenia, personality disorder and postpartum psychosis. The recurrence of mental health problems as a significant cause of maternal death emphasises that all HCPs have a role to play in identifying women in need of support and treatment.

Regardless of the setting, all HCPs can do some things to promote PMH and wellbeing if they encounter women in pregnancy and within the first 1 – 2 years after childbirth. Consider asking depression identification questions as part of a general discussion about mental health and wellbeing: “During the past month, have you often been bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by having little interest or pleasure in doing things?” (NICE, 2014). These questions cannot be used to diagnose or measure the severity of depression, and they are specifically used in pregnancy and the first year after birth however, they can be used to identify women who may require further evaluation. It is helpful to know the risk factors for perinatal mental health problems; in relation to postpartum depression, O’Hara & McCabe (2013) suggest three constellations of risk factors exist: a history of mild to severe psychiatric illness, life stress, and poor social relationships. Keeping up to date with local pathways of care for PMH services is vital for all HCPs, as well as having access to the appropriate referral numbers within the healthcare environment. Specialist PMH service provision is patchy across the United Kingdom (UK), however NHS England have invested in the development of specialist services in order to address gaps in provision, andSpecialist PMH community services should now be accessible in most areas. It is important to follow up any referrals to any services to ensure that women have been, or are in the process of having an assessment. Finally, common questions and fears of HCPs include “What if I make things worse by asking about mental health?” Talking about current or past mental health problems is unlikely to make things worse, and more likely to help women access the care and support they need. Research suggests that whilst some women, particularly those with histories of trauma, may find routine enquiry and disclosure difficult, most women welcome the opportunity to talk about mental health in antenatal booking appointments (Yapp et al., 2019). There is no reason to believe this is any different in non-maternity environments.

Reference List

Bauer A, Parsonage M, Knapp M, Iemmi V, Adelaja B (2014). The costs of perinatal mental health problems. London: London School of Economics and Political Sciences. Available from http://www.centreformentalhealth.org.uk/costs-of-perinatal-mh-problems

Glover V, O’Conner TG, O’Donnell K (2010) Prenatal stress and the programming of the HPA axis. Neuroscience & Biobehavioural Reviews. 35, pp 17 – 22.

Howard LM, Khalifeh H (2020) Perinatal mental health: a review of progress and challenges. World Psychiatry, 19, pp 313 – 327.

NICE (2014) Antenatal and postnatal mental health: clinical management and

Service guidance. National Institute for Health and Care Excellence. Clinical guideline

CG192. Available from https://www.nice.org.uk/guidance/cg192

O’Donnell KJ, Glover V, Jenkins J, Browne D, Ben-Shlomo Y, Golding J & O’Connor TG (2013) Prenatal maternal mood is associated with altered diurnal cortisol in adolescence. Pscyhoneuroendocrinology. 38:1630-1638.

O’Hara MW, McCabe J (2013) Postpartum depression: current status and future directions. Annual Review of Clinical Psychology. Volume 9, pp 379 – 407.

Yapp E, Howard LM, Kadicheeni M, Telesia LA, Milgrom J, Trevillion K (2019) A qualitative study of women’s views on the acceptability of being asked about mental health problems at antenatal booking. Midwifery, 74, pp 126 – 133.